Information Sheet for the Baccalaureate Nursing Program
 

This form can be completed online but must be printed for submission.  Do not extend beyond the areas visible (areas hidden from screen view will not print).  Please complete the following:

Name:    last   first   middle  
              maiden
Permanent Mailing Address:
Current Mailing Address:
City, state, county, zip:     Email address: 
Phone number (with area code):      Alternate number (cell):
MTSU Student M Number:      Optional: Race     Sex
Date of Birth:         Place (city, state):
Optional: Marital status         No. of children         Ages
Are you a ROTC?  Yes        No
Have you ever been enrolled in another school of nursing?  Yes        No
If yes, complete the following:

School                                                                             Reason for Leaving                                     List any specific nursing course(s)
                                                                                                                                                            you received a "C-" or below

Are you an R.N.? Yes   No        Are you an L.P.N.? Yes   No   License #

Name of RN/LPN School of Nursing          Address of School of Nursing                Type of Program                    Dates of Attendance
                                                                                                                          LPN/Associate/Diploma

Have you submitted application to the University (MTSU) for general admission?
                                Yes      No       Date submitted:
Have official transcripts been submitted to the Admissions Office?                                       
                                Yes      No       Date submitted:
Have official transcripts been submitted to the School of Nursing?                                      
                                Yes      No        Date submitted:

Have you ever been convicted of, or pleaded guilty to, a violation of the law other than a minor traffic violation?
Yes        No        If "Yes", please explain, give the date, and disposition of the case.

 An affirmative response will not necessarily be a bar to admission but may prohibit one from sitting for the RN Licensure exam.  Factors such as age at the time of conviction, elapsed time, seriousness and nature of the crime, and rehabilitation will be taken into account.  Students with a “Yes” answer to the question are advised to consult with the licensing board regarding their licensure eligibility.

Have you ever been involved in disciplinary action because of use, possession, or sale of a controlled substance (i.e., alcohol, drugs)? Yes        No      Nursing license revoked?  Yes        No              
Driver's license revoked? Yes        No           Dismissed from a job? Yes        No       
If "Yes", explain or see the school director*. 

Have you ever received care from a health professional for any major health problem?  Yes        No
Do you have any physical or mental health condition which would cause you or any other person to be placed in danger if you are admitted to the program?   Yes        No        If "Yes", please explain to the school director.
 

Because the MTSU School of Nursing seeks to provide in as much as possible a reasonably safe environment for its health career students and their patients, a student may be required, during the course of the program, to demonstrate his/her physical and/or emotional fitness to meet the essential requirements of the program.  Such essential requirements may include freedom from communicable disease, the ability to perform certain physical tasks, and suitable emotional fitness.  Any appraisal measures used to determine such physical and/or emotional fitness will be in compliance with Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990, so as not to discriminate against any individual on the basis of disability.

Please be aware that conviction of the following crimes would make you ineligible for Registered Nurse-licensure in the State of Tennessee:  Aggravated Assault, as in T.C. A. 39—13-102; First Degree Murder, as in T.C. A. 39-13-202; Second Degree Murder, as in T.C. A. 39-13-207; Voluntary Manslaughter, as in T.C.A. 39-13-211; False Imprisonment, as in T.C. A. 39-13-301; Kidnapping, as in T.C. A. 39-13-303; Aggravated Kidnapping, as in T.C. A. 39-13-304; Especially Aggravated Kidnapping, as in T.C. A. 39-13-305; Robbery, as in T.C. A. 39-13-401; Aggravated Robbery, as in T.C. A. 39-13-402; Especially Aggravated Robbery, as in T.C.A. 39-13-403; Aggravated Rape, as in T. C. A. 39-13-502; Rape, as in T.C. A.  39-13-503; Aggravated Sexual Battery, as in T.C. A. 39-13-504; Sexual Battery, as in T.C.A. 39-13-505; Statutory Rape, as in T.C. A. 39-15-506; Theft of Property, as in T.C. A. 39-14-103; Theft of Services, as in T.C. A. 39-14-104; Forgery, as in T.C.A. 39-14-114; Falsifying of Educational and Academic Records, as in T.C. A. 39-14-136; Arson, as in T.C. A. 39-14-301; Aggravated Arson, as in T.C. A. 39-14-302; Burglary, as in T.C. A. 39-14-402; Aggravated Burglary, as in T.C. A. 39-14-403; Especially Aggravated Burglary, as in T.C. A. 39-14-404; Incest, as in T.C. A. 39-15-302; Aggravated Child Abuse, as in T.C. A. 39-15-402; Sexual Exploitation of a Minor, as in T.C. A. 39-17-1003; Aggravated Sexual Exploitation of a Minor, as in T.C. A. 39-17-1004; Especially Aggravated Sexual Exploitation of a Minor, as in T.C.A. 39-17-1005; Assisted Suicide, as in T.C. A. 39-13-216; Rape of a Child, as in T.C. A. 39-13-522.

Please initial that you have read and understood this: ____________

Core Performance Standards Required for Nursing

Issue Standard Some Examples of Necessary Activities (not all inclusive)
Critical Thinking Critical thinking ability sufficient for clinical judgment Identify cause-effect relationships in clinical situations, develop nursing care plans
Interpersonal Interpersonal abilities sufficient to interact with individuals, families, and groups from a variety of social, emotional, cultural, and intellectual backgrounds Establish rapport with patients/clients and colleagues
Communication Communication abilities sufficient for interaction with others in verbal and written form Explain treatment procedures, initiate health teaching, document and interpret nursing actions and patient/client responses
Mobility Physical abilities sufficient to move from room to room and maneuver in small spaces Moves around in patient's rooms, work spaces, and treatment areas, administer cardiopulmonary procedures
Motor Skills Gross and fine motor abilities sufficient to provide safe and effective nursing care Calibrate and use equipment; position patients/clients
Hearing Auditory ability sufficient to monitor and assess health needs Hears monitor alarm, emergency signals, auscultatory sounds, cries for help
Visual Visual ability sufficient for observation and assessment necessary in nursing care Observes patient/client responses
Tactile Tactile ability sufficient for physical assessment Perform palpation, functions of physical examination and/or those related to therapeutic intervention, e.g., insertions of a catheter

Please initial that you have read and understood this: ____________

Universities/Colleges attended (if any including MTSU) with dates of attendance:
Signature:___________________________________________________________________

Date of this application:

*Some of these circumstances could prevent you from obtaining a Registered Nurse license in Tennessee.

Mail to Director, School of Nursing, Box 81, Middle Tennessee State University, Murfreesboro, TN  37132


A Tennessee Board of Regents University
MTSU is an equal opportunity, nonracially identifiable, educational institution that does not discriminate against individuals with disabilities.  AA283-0505